=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962962670
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA NOVAK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2019
-----------------------------------------------------
Last Update Date | 03/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 E STATE ST
-----------------------------------------------------
City | SAINT CROIX FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54024-4117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-483-0260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 216 S ADAMS ST
-----------------------------------------------------
City | SAINT CROIX FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54024-9449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 15913-40
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------